Inaccurate Cognitive and Incomplete Fall Risk Assessments for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate resident assessments for one of three sampled residents. The Director of Staff Development reported that, during an investigation into this resident’s death, he reviewed the resident’s Brief Interview of Mental Status (BIMS) score and found the last quarterly summary showed a score of 1, which he could not understand because, as a licensed nurse familiar with the resident, he believed the resident was alert and oriented. In a concurrent interview and record review, the MDS nurse stated that when she assessed the resident during the last quarter, she would have scored the BIMS at 3, and on review of the documented BRIEF INTERVIEW FOR MENTAL STATUS form, she noted it showed a score of 1 and stated that social services staff had completed and scored it incorrectly. She further stated the resident had capacity to make his own decisions and was his own responsible party. A Physician Orders for Life-Sustaining Treatment (POLST) form in the record, signed by the resident, indicated that the patient had capacity. Record review also showed that the resident’s fall risk assessment was incomplete. A NURSING - FALL RISK OBSERVATION / ASSESSMENT form for the resident indicated a score of 18, which corresponded to high risk, but the assessment had not been completed and was signed by the MDS nurse. Additional documentation titled NURSING - ELOPEMENT AND WANDERING RISK OBSERVATION ASSESSMENT indicated the resident was able to move or propel himself in a wheelchair with some assistance, had no communication, hearing, or vision deficiencies, and that the care plan had been initiated or updated to reflect interventions aimed at reducing the risk of unsafe wandering or elopement. A subsequent elopement and wandering risk assessment documented that the resident had expressed plans to leave but had not attempted to leave the facility, again noting no communication, hearing, or vision deficiencies and that interventions were reflected in the care plan.
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